From the Guidelines
An 84-year-old man with iron deficiency anemia should undergo a colonoscopy to evaluate for potential gastrointestinal bleeding, particularly colorectal cancer, as the benefits of detecting and treating potential malignancy outweigh the risks of the procedure, according to the British Society of Gastroenterology guidelines 1.
Key Considerations
- The patient's age and sex are independent predictors of risk of GI cancer in IDA, and therefore, a colonoscopy is warranted regardless of age 1.
- Before proceeding, the patient should have standard pre-colonoscopy preparation, typically including a clear liquid diet the day before, along with a bowel preparation solution such as polyethylene glycol (GoLYTELY, MoviPrep) or sodium picosulfate.
- The patient's medical history, comorbidities, and medication use (especially anticoagulants) should be carefully reviewed to assess procedural risks 1.
Alternative Options
- If colonoscopy is deemed too risky, alternative less invasive options like CT colonography could be considered, as it is a reasonable alternative in patients not suitable for colonoscopy 1.
- Fecal immunochemical testing is not recommended for risk stratification in patients with IDA, as the evidence base is evolving rapidly and currently insufficient 1.
Overall Health Status
- Consideration should be given to the patient's overall health status and life expectancy, as the benefits of detecting and treating potential malignancy must outweigh the risks of the procedure 1.
- The patient's views and those of their family should be taken into account when discussing the potential risks and benefits of invasive investigation 1.
From the Research
Evaluation of Iron Deficiency Anemia
The evaluation of iron deficiency anemia (IDA) in an 84-year-old man involves investigating potential sources of gastrointestinal bleeding. According to 2, anemia with iron deficiency but without overt GI bleeding is associated with a risk of malignant disease of the gastrointestinal tract.
Diagnostic Approach
The recommended diagnostic strategy for unexplained anemia with iron deficiency includes conducting serological celiac disease screening and performing bidirectional endoscopy (gastroscopy and colonoscopy) 2. A study published in 3 suggests that bidirectional endoscopy is highly sensitive and specific in locating gastrointestinal lesions resulting in iron deficiency anemia.
Colonoscopy
Colonoscopy is a crucial diagnostic tool in evaluating IDA, especially in older adults. As stated in 3, the possibility of malignant disease dictates that initial colonoscopy be performed in all but a few cases involving distinct upper gastrointestinal risk factors and symptoms. A study in 4 found that diseases associated with bleeding, including colon cancer, were detected in 37% of patients with IDA.
Risk Factors
Certain risk factors can predict the outcome of endoscopic evaluation of IDA. According to 5, male gender, advanced age, and lower mean corpuscular volume are risk factors for GI malignancies. Additionally, greater age, absence of lower-GI tract symptoms, and a positive fecal occult blood test are risk factors for bleeding-related diseases.
Diagnostic Recommendations
Based on the evidence, an 84-year-old man with IDA should undergo a colonoscopy as part of the diagnostic evaluation to investigate potential sources of gastrointestinal bleeding. As suggested in 5, colonoscopy should be the initial investigation in patients greater than 50 years of age, particularly men, and those without upper-GI tract symptoms.
Key Findings
- Bidirectional endoscopy is recommended for evaluating IDA 2, 3
- Colonoscopy is crucial in detecting gastrointestinal lesions, including colon cancer 3, 4
- Risk factors, such as age and gender, can predict the outcome of endoscopic evaluation 5
- A diagnostic approach that includes colonoscopy is necessary to investigate potential sources of gastrointestinal bleeding in an 84-year-old man with IDA 2, 3, 5